insect sting allergy - anthygenus€¦ · insect sting allergy david f. graft, mda,b,* aasthma and...

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Insect Sting Allergy David F. Graft, MD a,b, * a Asthma and Allergic Diseases, Park Nicollet Clinic, Minneapolis, MN, USA b Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN, USA The study of allergy to insect stings holds a unique position in the field of allergy, and because of the usually singular and notable times of exposure, it serves as a model for the development, natural history, and treatment of al- lergic phenomena. The death of King Menes of Egypt shortly after a wasp sting is often cited as one of the earliest historical examples of anaphylaxis [1]. Soon after the concepts of anaphylaxis were defined by Portier and Richert in 1902 [2], generalized reactions to insect stings were recognized as hypersensitivity phenomena [3]. Ten years later, Braun [4] described a typ- ical patient with insect sting sensitivity and his use of insect venom for diag- nosis and treatment. Although this initial treatment used the posterior one eighth inch of the insect to increase the yield of venom, that stipulation was later ignored and for decades, immunotherapy with whole-body extract was used for the treatment of patients with insect sting reaction [5]. In the 1950s and 1960s, events occurred that eventually led to the development of venom immunotherapy (VIT). Loveless and Fackler [6] reported the successful di- agnostic and therapeutic use of extracts of venom sacs. Bernton and Brown [7] and Schwartz [8] independently found that whole-body extract skin tests did not discriminate insect allergic patients from subjects with no history of generalized reactions. Methods for collecting large quantities of honeybee venom were developed and the venom contents were characterized [9]. Ves- pid venom collection was more difficult requiring venom sac extirpation in a tedious one-insect-at-a-time process. In the 1970s, a few case reports of successful VIT appeared [10,11] and then, in 1978, Hunt and coworkers [12] from Johns Hopkins reported a challenge sting trial in which the supe- riority of VIT was demonstrated when compared with whole-body extract and placebo injections. The immunotherapy protocol with venom is the most effective treatment in the field of allergy. About 97% of venom-treated * Asthma and Allergic Diseases, Park Nicollet Clinic, 3800 Park Nicollet Boulevard, Minneapolis, MN 55416. E-mail address: [email protected] 0025-7125/06/$ - see front matter Ó 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.mcna.2005.08.006 medical.theclinics.com Med Clin N Am 90 (2006) 211–232

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  • Med Clin N Am 90 (2006) 211–232

    Insect Sting Allergy

    David F. Graft, MDa,b,*aAsthma and Allergic Diseases, Park Nicollet Clinic, Minneapolis, MN, USA

    bDepartment of Pediatrics, University of Minnesota Medical School, Minneapolis, MN, USA

    The study of allergy to insect stings holds a unique position in the field ofallergy, and because of the usually singular and notable times of exposure, itserves as a model for the development, natural history, and treatment of al-lergic phenomena. The death of King Menes of Egypt shortly after a waspsting is often cited as one of the earliest historical examples of anaphylaxis[1]. Soon after the concepts of anaphylaxis were defined by Portier andRichert in 1902 [2], generalized reactions to insect stings were recognizedas hypersensitivity phenomena [3]. Ten years later, Braun [4] described a typ-ical patient with insect sting sensitivity and his use of insect venom for diag-nosis and treatment. Although this initial treatment used the posterior oneeighth inch of the insect to increase the yield of venom, that stipulation waslater ignored and for decades, immunotherapy with whole-body extract wasused for the treatment of patients with insect sting reaction [5]. In the 1950sand 1960s, events occurred that eventually led to the development of venomimmunotherapy (VIT). Loveless and Fackler [6] reported the successful di-agnostic and therapeutic use of extracts of venom sacs. Bernton and Brown[7] and Schwartz [8] independently found that whole-body extract skin testsdid not discriminate insect allergic patients from subjects with no history ofgeneralized reactions. Methods for collecting large quantities of honeybeevenom were developed and the venom contents were characterized [9]. Ves-pid venom collection was more difficult requiring venom sac extirpation ina tedious one-insect-at-a-time process. In the 1970s, a few case reports ofsuccessful VIT appeared [10,11] and then, in 1978, Hunt and coworkers[12] from Johns Hopkins reported a challenge sting trial in which the supe-riority of VIT was demonstrated when compared with whole-body extractand placebo injections. The immunotherapy protocol with venom is themost effective treatment in the field of allergy. About 97% of venom-treated

    * Asthma and Allergic Diseases, Park Nicollet Clinic, 3800 Park Nicollet Boulevard,

    Minneapolis, MN 55416.

    E-mail address: [email protected]

    0025-7125/06/$ - see front matter � 2005 Elsevier Inc. All rights reserved.doi:10.1016/j.mcna.2005.08.006 medical.theclinics.com

  • 212 GRAFT

    patients have no reaction when stung [13–15]. The few remaining patientsare more appropriately considered partial successes rather than treatmentfailures because they tend to have reactions that are much less severe thanthose they have previously experienced.

    Insect venoms for immunotherapy became commercially available in1979. Since then, thousands of patients have received VIT. Venom injectionsgreatly reduce the likelihood of serious allergic reactions and consequentlyimprove the patient’s quality of life by reducing anxiety and allowing pa-tients to participate in the outdoor activities that they prefer. Guidelineshave been published regarding the selection of patients and the method ofVIT and for the discontinuation of VIT [16,17]. Venom injections haveproved very safe, with a low occurrence of injection-induced systemic reac-tions and no reports of fatal reactions. Unfortunately, even after 25 years ofuse, many patients who should initiate VIT are not referred to allergists forevaluation despite data that demonstrate the lack of effectiveness of single ormultiple doses of epinephrine [12,18]. It is hoped that this pattern of under-utilization will diminish in the future.

    Epidemiology

    Systemic allergic reactions are reported by 0.4% to 3% of individuals[19–21]. There is a 2:1 male/female ratio that is probably a reflection of rel-ative exposure. About one third of those experiencing allergic sting reactionsare atopic [22]. Annually, about 45 deaths are attributed to insect stings inthe United States (Table 1) [23]. Other data on fatal stings include the fol-lowing: 20 in Ontario, Canada, from 1986 to 2000 [24]; four per year inthe United Kingdom [25]; three per year in Switzerland [26]; and 11 peryear in West Germany [27]. About one half of the fatal reactions occur inindividuals with no prior history of allergic reactions to stings [28,29].Many more men (about 3.5-fold) than women die from insect sting reac-tions, and greater than 80% of the deaths from insect stings occur in personsover 40 years of age [23]. The coexistence of coronary heart disease, athero-sclerosis, or emphysema may determine a more severe outcome. The truenumber of deaths attributed to insect stings is undoubtedly higher becausesudden deaths on a golf course or while working outside may be falsely la-beled as heart attacks or strokes. In studies of postmortem sera from indi-viduals dying from unknown causes, a significant number had clinicallyrelevant levels of IgE antibodies to one or more Hymenoptera venom or el-evated tryptase levels [30,31]. There are many more near-fatal episodes. Inthe initial controlled trial of VIT, 3 of the 14 patients in the placebo- andwhole-body extract–treated groups who sustained challenge sting-inducedsystemic reactions had significant hypotension; in two of these patientsthe hypotension persisted despite multiple doses of epinephrine; one patientrequired intubation [18].

  • 213INSECT STING ALLERGY

    The rate of venom sensitivity is higher than the rate of systemic reactions.In a stratified random sample of 320 adults in a light industrial setting, 3.3%had a history of systemic reaction to insect sting, but 17% had positivevenom skin test (VST) and 26% had venom-specific IgE antibodies by ra-dioallergosorbent testing (RAST) [21]. Evidence of venom sensitivity wasmore likely if the subject had been stung in the last 3 years. Interestingly,these history-negative positive VST subjects had a 17% risk of reaction tofield sting [32]. Ludolph-Hauser and coworkers [33] reported a more fre-quent occurrence of elevated basal serum tryptase in patients with a historyof severe systemic reactions to insect stings. Others have also reported severereactions to insect stings in patients with systemic mastocytosis and oftenlittle evidence of venom sensitization is found [34].

    The insects

    The stinging insects belong to the order Hymenoptera. A sting is an in-jection of venom by the female of each species through a modified ovipos-itor. The most conspicuous members of the superfamily Apidae are thehoneybee (Apis mellifera) and bumblebees (Bombus spp). Honeybees aresmall, fuzzy insects with alternating tan and black stripes. They are often

    Table 1

    Insect sting deaths in the United States

    No. of deathsTotal for

    the yearYear 0–9 10–19 20–29 30–39 40–49 50–59 60–69 70þ Sex (M/F)1980 0 0 1 1 7 13 13 3 38 25/13

    1981 0 1 2 7 6 12 6 5 39 35/4

    1982 0 1 2 4 16 13 10 8 54 45/9

    1983 2 0 3 8 9 9 10 8 49 43/6

    1984 4 0 2 5 11 8 14 4 48 39/9

    1985 1 1 4 4 8 10 9 4 41 32/9

    1986 0 0 2 8 7 7 11 7 42 31/11

    1987 1 0 0 5 9 15 12 11 53 42/11

    1988 0 0 1 3 7 8 9 6 34 27/7

    1989 0 0 2 6 9 13 15 8 53 40/13

    1990 0 1 3 4 6 11 10 3 38 33/5

    1991 1 1 4 11 11 13 14 9 64 48/16

    1992 0 0 2 10 13 10 8 5 48 38/10

    1993 0 2 1 6 8 5 11 6 39 31/8

    1994 0 1 2 7 12 6 13 8 49 37/12

    1995 0 1 0 7 12 13 11 15 59 46/13

    1996 0 1 1 2 9 14 12 6 45 27/18

    1997 0 1 5 5 10 10 10 2 43 40/3

    1998 1 0 4 4 13 12 4 8 46 33/13

    1999 0 0 0 5 13 15 5 5 43 31/12

    Total 10 11 41 112 196 217 207 131 925 723/202

    Data from Graft DF. Venom immunotherapy for stinging insect allergy. Clin Rev Allergy

    1987;5:149–59.

  • 214 GRAFT

    seen pollinating clover and flowering plants, are relatively nonaggressive,and generally sting only when caught underfoot. The barbs along the shaftof the honeybee stinger cause it to remain embedded at the sting site (auton-omy). As it flies away, the honeybee dies through evisceration.

    The honeybees in the United States were at one time only of Europeanancestry. Africanized honeybees were brought to Brazil in 1956 to improvehoney production. One year later multiple colonies escaped and began inter-breeding with the resident colonies. The Africanized honeybees have ex-panded northward and by 2002 were present in most of Texas andArizona and southern areas of Nevada, California, and New Mexico. Afri-canized honeybees are often referred to as ‘‘killer bees’’ not because of in-creased venom potency or allergenicity but rather of their tendency toattack en masse; fortunately, even massive stinging incidents of 50 to 100stings are not usually fatal. Nevertheless, there were at least 70 deaths attrib-uted to Africanized honeybees in Venezuela from 1978 to 1981 [35] and 42deaths in Mexico from 1987 to 1991 [36]. McKenna [36] recently accountedthe 13 deaths in the United States until 2002.

    Bumblebees are large, slow-moving, noisy bees with hairy bodies of alter-nating yellow and black stripes. They are also nonaggressive and accountfor only a small fraction of stings. Bumblebee stings have become morecommon, however, because they have been used in confined settings, suchas greenhouses, to pollinate tomato plants [37].

    The family Vespidae includes the yellow jackets, hornets, and wasps,which make papier-mâché–like nests of wood fiber. The more than 10 spe-cies of yellow jackets (Vespula spp) are identified by alternating yellow andblack body stripes. They usually nest in the ground or in decaying logs nearhuman dwellings and scavenge for food. Closely related are the yellow andwhite (bald-faced) hornets (also Vespula spp), which build teardrop-shapednests that hang in trees or bushes. Both yellow jackets and hornets are ex-tremely aggressive, especially in the late summer when crowded conditionsdevelop in the nests.

    Not quite as aggressive as the other vespids, the thin-bodied paper wasps(Polistes spp) build nests in the eaves of buildings in which the developmentcells are not enclosed by a paper envelope. Allergic reactions resulting fromwasp stings account for less than 5% of the cases in the northeast; however,in the southern regions of the United States, they are much more prevalent.Vespids rarely leave a stinger at the sting site, a feature that can be a clue inculprit identification.

    Interestingly, common names for these insects are different in the UnitedStates and Europe and this must be kept in mind when reviewing the liter-ature [38]. The yellow jacket, yellow hornet, and paper wasp are all calledwasps in Europe. The term ‘‘hornet’’ is reserved in Europe for the Vespacrabro (European hornet), a large insect that builds its nests in tree hollowsand wall cavities. Fortunately, still relatively uncommon in the UnitedStates, they account only for a small fraction of stings.

  • 215INSECT STING ALLERGY

    The imported fire ant (Solenopsis invicta) is found in the southeasternand south central United States. Its range continues to increase and allergicreactions to fire ants are becoming more common [39]. The fire ant graspsthe victim with its jaws, then pivots around, stinging repetitively in a semi-circular pattern. The hallmark of their sting is the development of a sterilepustule at each sting site 24 hours later.

    Venoms

    The dried weight of the venom deposited by a honeybee, induced to stinga plastic film, is approximately 50 mg. A single sting from a yellow jacket isthought to deliver between 10 and 100 mg. Hymenoptera venoms containa number of interesting constituents [40]. Most of the venoms contain hista-mine, dopamine, acetylcholine, and kinins, which cause the characteristicburning and pain and may allow for access to the systemic circulation.The allergens in the venoms are mostly proteins with enzyme activity. Al-though honeybees and have both phospholipase and hyaluronidase activi-ties in their venom, the proteins bearing the same enzymatic functions invespid venoms are immunochemically different. Antibody inhibition studieson sera from mice immunized with purified venom allergens show that ex-tensive cross-reactivity exists between white-faced hornet, yellow hornet,and yellow jacket for hyaluronidase and antigen 5, but not phospholipase[41,42]. There is some cross-sensitization between Polistes wasp and yellowjacket for antigen 5 and there is limited cross-reactivity between honeybee,vespid, and fire ant venoms.

    Spectrum of reactions

    Following a Hymenoptera sting, most individuals experience a small ur-ticarial area that is slightly raised with surrounding redness, pruritus, andpain that starts shortly after the sting and usually resolves in 2 to 3 hours.About 10% of the population develop large local reactions, which hasbeen variably defined as swelling contiguous with the sting site larger thana 2-in diameter [43] or more than a 4-in diameter [44] lasting over 24 hours.Occasionally, these are large enough to involve an entire extremity and maylast for as long as a week. Often, these are misdiagnosed as cellulitis and pa-tients receive antibiotics, especially if there is a lymphatic streak toward theaxilla or groin.

    Systemic allergic reactions (anaphylaxis) may be mild with only cutane-ous symptoms (pruritus; urticaria; angioedema of the eyes, lips, hands;and so forth) or severe with potentially life-threatening symptoms of laryn-geal edema, bronchospasm, hypotension manifested by an uncomfortablefeeling in the throat, gagging, difficulty swallowing, voice change, inspira-tory stridor, chest tightness, wheezing, cough, dizziness, tunnel vision, or

  • 216 GRAFT

    loss of consciousness. Adults often describe a metallic taste in their mouthor an aura of impending doom, as if they are going to die. Nausea is com-mon in large local and systemic reactions.

    Systemic allergic reactions are, in general, less severe in children thanadults. Of the approximately 45 deaths per year in theUnited States attributedto insect stings, only one or two occur in children [23]. Whereas 85% of adultswith sting-induced systemic reactions report potentially life-threateningsymptoms, such as laryngeal edema, bronchospasm, or hypotension, only40% of children develop reactions of this level of severity [45]. Diagnosis ofanaphylaxis is sometimes complicated by the absence of the more easily rec-ognized cutaneous symptoms of an allergic reaction, such as urticaria. A pa-tient may complain of light-headedness or a brief period of unconsciousness,be found to have hypotension, and the diagnosis of vasovagal reactionmay bemade. A vasovagal reaction is usually accompanied by bradycardia, however,whereas anaphylaxis often includes compensatory tachycardia in response tovasodilation and leakage of fluid from the blood vessels. An elevated serumtryptase, which signals mast cell degranulation, provides additional evidencefor anaphylaxis [46].

    Solley [47] recently reported his 17-year experience with insect stings andbites from Queensland, Australia. Of 1194 patients with anaphylaxis, 775had urticaria with dyspnea, 425 had facial angioedema, and 457 had asthma.Additionally, 454 (38%) reported dizziness and 179 (15%) more patientsmanifested unconsciousness. Of particular note, 82 patients (7%) experi-enced dizziness, faintness, weakness, or coma as their sole expression of ana-phylaxis; 48 (4%) had airways obstruction only; and an additional 79 (7%)had a combination of these two only.

    A variety of atypical reactions have been described after insect stings[48,49]. When the syndrome of urticaria, fever, proteinuria, lymphadenopa-thy, and arthropathy has occurred, it has been termed ‘‘serum sickness’’ de-spite the imperfect analogy to classic serum sickness. Although one mightworry that symptoms of serum sickness might recur when VIT is used,that has not been reported. Other uncommon outcomes after insect stingsincluding renal disease and neurologic manifestations have been described,but they have not been shown to be IgE-mediated, and the mechanism ofthese events is unclear.

    Treatment of acute sting reactions

    Minor local swelling and pruritus are expected and can be treated with iceand antihistamines. If present, the imbedded stinger should be flicked offwith a scraping motion. Some authorities believe that one should not graspthe fleshy venom sac to extract the stinger because more venom might thenbe injected through the stinger. Schumacher and colleagues [50], however,showed that essentially the entire honeybee venom load is injected in lessthan 20 seconds; one should quickly remove the stinger.

  • 217INSECT STING ALLERGY

    If a generalized reaction occurs, epinephrine is the keystone of manage-ment. Epinephrine halts the further release of mediators and reversesmany of the effects of released mediators. An intramuscular (preferred)[51] or subcutaneous injection of epinephrine usually produces prompt res-olution of symptoms. The dose of epinephrine is 0.3 to 0.5 mg (0.3 to 0.5 mLof a 1:1000 solution) for adults, and 0.01 mg/kg for children. This may berepeated in 10 to 15 minutes if necessary. An oral or parenteral antihista-mine, such as diphenhydramine, 6.25 to 50 mg, is also usually given. Itmay lessen urticaria, but in more severe or progressive reactions, its useshould not delay the administration of epinephrine.

    Epinephrine may be ineffective in profound anaphylactic shock unless thefunctional hypovolemia of this state is corrected with intravenous fluids [18].Severe reactions often require treatment with oxygen, H2-antihistamines,and pressor agents. Corticosteroids are often used but they have a delayedonset of action. Intubation or tracheostomy is indicated for severe upper air-way edema not responding to therapy. Close observation is essential. Over-night hospitalization is suggested for patients who have experienced severereactions or who have complicated medical problems.

    Decreasing future reactions

    Preventing stings

    Future stings can be avoided by taking common sense precautions to sig-nificantly reduce exposure. Shoes should always be worn outside. Hives andnests around the home should be exterminated. Good sanitation should bepracticed because garbage and outdoor food, especially canned drinks, at-tract yellow jackets. Unfortunately, insect repellents have little or no effect.Avoidance of attractants, such as fragrances and brightly colored clothes,may be helpful.

    Emergency epinephrine

    To encourage prompt treatment, epinephrine is available in emergencykits for self-administration. These are used by insect sting–allergic individ-uals immediately after the sting to ‘‘buy time’’ to get to a medical facility.A practice self-injection with saline helps to allay such fears. The EpiPen(0.3 mg epinephrine) and EpiPen Jr. (0.15 mg epinephrine) offer a concealedneedle and a pressure-sensitive spring-loaded injection device that makethem suited for patients and families who are uncomfortable with the injec-tion process. Epinephrine by inhalation may also be used to achieve a ther-apeutic plasma level and may be especially helpful for laryngeal edema andbronchospasm. Many patients in urgent care settings do not receive a pre-scription for self-administered epinephrine or referrals to allergists for con-sideration of VIT [52]. Patients who are receiving maintenance injections of

  • 218 GRAFT

    VIT are advised that emergency self-treatment will probably not be re-quired; however, they should have the kit available if they are distant frommedical facilities. A Medic-Alert bracelet is also advised.

    How to initiate venom immunotherapy

    Patient selection

    VIT is a safe, highly effective method of preventing future sting reactionsin insect-allergic patients. The selection of patients for VIT is determined bythe likelihood that a future sting will cause an allergic reaction (Table 2),which is based on the clinical history and the results of venom skin tests(VSTs) (and occasionally RASTs). The risk of recurrence is higher for adultsthan for children, higher for those allergic to honeybee rather than vespidvenom, and higher for patients whose previous reactions were more severe[53–55]. A careful history discloses the type, degree, and time course ofsymptoms, and often identifies the culprit insect. An individual who has ex-perienced a sting-induced systemic reaction should be referred to an allergistwho will perform skin tests with dilute solutions of honeybee, yellow jacket,yellowhornet, white-faced hornet, andPolisteswasp venoms and, if indicated,imported fire ant whole-body extract [56,57]. RAST cannot replace VSTbut may provide additional information [58]. The value of venom RAST isdiscussed in a subsequent section on the VST-negative patient. To date, fireant venom has only been available in small research quantities; fortunately,the fire ant whole-body extract material contains a significant amount ofvenom and has been successfully used for skin testing and treatment. Table 3lists the indications for VIT. At particularly low risk are children who havehad reactions limited to the skin in which there is only a 10% rate of sub-sequent systemic reactions involving respiratory or cardiovascular symp-toms [53]. Children who have had moderate or severe reactions shouldstart VIT; those who do not start VIT have a significantly higher risk of

    Table 2

    Risk of systemic reaction in untreated patients with a history of sting anaphylaxis and positive

    venom skin tests

    Original sting reaction Risk of systemic reaction (%)

    Severity Age 1–9 y 10–20 y

    No reaction Adult 17 d

    Large local All 10 10

    Cutaneous Child 10 5

    Systemic Adult 20 10

    Anaphylaxis Child 40 30

    Adult 60 40

    From Golden DBK. Insect allergy. In: Adkinson NF, Middleton E, editors. Middleton’s

    allergy: principles and practice. 6th edition. Philadelphia: Mosby; 2003. p. 1475–86.

  • 219INSECT STING ALLERGY

    reaction as adults, estimated to be 30% [59]. Some clinicians recommendVIT for an adult who experienced any degree of systemic reaction. Most in-dividuals, however, have a stereotypic response to a sting with the symptomson subsequent stings closely resembling the first episode [60]. When onlya mild reaction has occurred, the physician and patient may jointly decidewhether to embark on a course of VIT [61]; some experts advise treatmentof adults with only cutaneous symptoms [62]. Individuals who have had se-vere allergic reactions should be advised not to depend only on avoidanceand availability of epinephrine but also to receive venom injections. Patientswith a history of systemic reactions have a reduced quality of life [63]; this isnot improved by having self-administered epinephrine but is with VIT [64].

    Individuals with large local reactions or negative skin tests are not candi-dates for venom therapy. The risk of anaphylaxis to future stings is about 5%to 10% in patients who have had large local reactions to insect stings; many,however, develop large local reactions again [43,44,65]. Many patients withlarge local reactions have evidence of a high level of venom sensitivity. Be-cause it is also true that some patients with severe anaphylaxis have low levelsof venom sensitivity, the level of skin test reactivity (and venom-specific IgE)is poorly correlated with the risk of systemic reactions [56]. A positive VST orRAST in the absence of a sting-induced systemic reaction is not an indicationfor therapy. Approximately 25% of the general population may have suchevidence of sensitization to venom antigens, apparently resulting from paststings. This is usually transient, disappearing in 1 to 3 years [21].

    Other factors may influence the decision concerning the need for VIT.Those with an increased risk of being stung, such as landscapers or otherindividuals who engage in outdoor activities, especially those that takethem far away from available medical care, dispose the physician toward

    Table 3

    Selection of patients for immunotherapy

    Reaction to sting

    Result of skin

    test or RAST

    Venom

    immunotherapy?

    Child

    Systemic, non–life-threatening, immediate, generalized

    urticaria, angiodema, erythema, pruritusaþ or � No

    Systemic, life-threatening, possible cutaneous symptoms,

    but also respiratory symptoms (laryngeal edema or

    bronchospasm) or cardiovascular symptoms

    (hypotension, shock)

    þ Yes

    Adult

    Systemic þ YesSystemic � No

    Child or adult

    Large local (O2 in diameter, O24-h duration) þ or � NoNormal (!2 in, !24-h duration) þ or � Noa It is unknown whether this rule applies to imported fire ant hypersensitivity in children.

  • 220 GRAFT

    initiating venom treatment. Part of the morbidity associated with stinginginsect allergy includes psychologic effects of anxiety in the victim and familybecause of the threat of a sudden ‘‘unpreventable’’ systemic reaction. Thishigh level of anxiety has frequently been exacerbated by a physician warningthat ‘‘the next sting may be your last.’’ Actually, most victims exhibit an in-dividual pattern of anaphylaxis that varies only slightly in severity from onesting to another. Some investigators have proposed that a diagnostic stingchallenge be used to select patients for VIT [60]. Patients who did not reactwould not be placed on VIT. Other reports, however, have described indi-viduals who tolerated one sting challenge, but reacted later to a second chal-lenge [66,67]. In the United States, the use of sting challenges to determineVIT candidates is impractical and most physicians believe that a challengesting presents too great a risk [68], especially for patients with life-threateningreactions (ie, hypotension). Indeed, in one study life-threatening reaction re-curred in 15% of subjects with histories of severe reactions [60].

    The venom skin test–negative patient (never say never)

    The patientwith a history of a sting-induced systemic reaction and negativeVSTs presents a unique challenge. It has been commonly assumed that nega-tive VST responses indicate that there is no risk of systemic reaction to a sting.Golden and coworkers [69] recently reported, however, that of 307 subjectswith a history of a sting-induced systemic reaction who underwent VST, 99(32%) had negative VST. Of these, negative RASTwas present in 56 patients;36 had low (1–3 ng/mL)RAST; and 7 had high positiveRAST (4–243 ng/mL).Sting challenges in 14 of 56 patients with negative VST and negative RASTresulted in two (14%) systemic reactions. Sting challenges in 37 of 43 patientswith negative VST and positive RAST caused nine (24%) systemic reactions.Combined, the negative VST group had a systemic reaction rate of 22%,which was similar to the rate of 21% found in those with positive VST studiedat the same time. It is now recommended that a patient with a convincing his-tory of a sting-induced systemic reaction should have VST. If these are nega-tive and the reaction was severe, venom-specific IgE should be measured andVIT initiated if positive. If negative RASTs are obtained, the VST should berepeated 3 to 6months later [70,71].Regardless of theVST and venom-specificIgE determinations, the patient should practice usual precautions of insectsting avoidance and should carry antihistamines and injectable epinephrine.

    Venom selection

    The venoms used for immunotherapy are the same as those used for skintesting (honeybee, yellow jacket, yellow hornet, white-faced hornet, wasp,and fire ant whole-body extract if applicable). The regimen begins with an in-jection of 0.01 mg and advances weekly to 100 mg (0.5 of 1:100 wt/vol for fireant whole-body extract). The maintenance dose of 100 mg is given every4 weeks for a year, after which the interval is lengthened to 6 to 8 weeks.

  • 221INSECT STING ALLERGY

    The choice of venoms is based primarily on VST results, and to a lesserextent on clinical history and patterns of venom cross-reactivity. It is cur-rently recommended that immunotherapy include all venoms giving a posi-tive skin test, the aim being to give the maximum security to the patient [62].Even a patient who has reacted to only one type of insect should not be leftwith lingering doubts about future stings by other insects to which he or sheshows skin test sensitivity. The most common culprit in North Americais the yellow jacket, except for some areas of the south central and south-western states, where wasps and honeybees, respectively, are predominant.In some cases, the skin tests are positive to only one or two venoms.Most yellow jacket–allergic patients also have positive skin tests to yellowhornet and white-faced hornet venoms, however, and consequently requiretreatment with mixed vespid venom containing the full dose of each venom(yellow jacket, yellow hornet, and white-faced hornet). Half of these patientsare also positive to Polistes wasp venom and receive this in addition. RASTinhibition studies candisclosewhether patients are sensitive to a cross-reactingallergen or multiple unique allergens. The allergenic cross-reactivity of thefour vespid venoms has been demonstrated, as has the fact that mostpatients with multiple vespid venom sensitivity can be fully protected by im-munotherapy with yellow jacket venom alone [72,73]. Honeybee venom isadministered as indicated.

    The 100-mg maintenance dose of venom was initially chosen because itrepresented approximately twice the venom content of a honeybee sting.One investigator has reported his 10-year experience with a maintenancevenom dose of 50 mg [73]. The question of whether or not a lesser dose wouldsuffice was examined in a group of patients who received a 50-mg mainte-nance dose. It was found that with the reduced venom dose, only 79%of subjects were protected from challenge sting-induced systemic reactions[74].

    Yunginger and coworkers [75] reported on a very rapid 1-day rush regi-men that had some success but caused many systemic reactions and had tobe performed in a hospital. Bernstein and colleagues [76] described a 2- to5-hour regimen of rush VIT in which 10 gradually increasing doses were ad-ministered every 10 to 15 minutes to achieve a total dose on day 1 of about55 mg per venom followed by doses of 70, 80, 90, and 100 mg on days 3, 7, 14,and 21, respectively. Only 4 of 33 patients had reactions on day 1, and allwere mild. These patients subsequently tolerated natural stings withoutincident.

    How does venom immunotherapy work?

    The mechanism of action of immunotherapy is only partially understood.The development of allergic sensitization to venom requires the sting-inducedproduction of venom-specific IgE antibodies that are bound to tissue mastcells and circulating basophils. A subsequent sting may then result in the

  • 222 GRAFT

    binding of venom antigens to the IgE molecules followed by the release ofmast cell and basophil mediators of anaphylaxis (histamine, leukotrienes,and so forth). It should be remembered that venom vaccines used to immu-nize patients with insect sting hypersensitivity are not clinically or immuno-logically identical to the venom injected by live stings. In the initial controlledtrial of VIT, some patients tolerated injections of 100 mg of venom adminis-tered subcutaneously immediately before challenge stings that caused severeanaphylaxis to challenge stings [12,18]. Successful VIT is associated withmany humoral and cellular immunologic changes that are summarized ina recent review [77].

    VIT results in significant changes in venom-specific IgE and IgG anti-body levels. IgE rises first, peaking at 8 to 12 weeks, before declining slowlyover 3 to 5 years to pretreatment levels. The IgG level reaches its mean peakvalue of 15 mg/mL at 2 to 4 months, and then is fairly constant over 5 to 6years of treatment in children. Adults have an average peak of 9 mg/mL andthen decline to about 6 mg/mL. A few adult patients experience even moreextreme declines for reasons that are presently unclear. The cause of themore vigorous IgG response in children is also not known. Analysis ofvenom-specific IgG levels in children and patient age, body weight, or sur-face area fails to show any correlation [78].

    The production of antigen-specific IgG (blocking) antibodies has beenconsidered the possible means of immunotherapeutic improvement. Lessofand coworkers [79] demonstrated that honeybee-allergic patients could tol-erate challenge stings after passive immunization with the gamma globulinfraction of pooled beekeeper’s serum that contained a high blocking anti-body titer. The serum level of venom-specific IgG has been inversely corre-lated with the likelihood of challenge sting-induced systemic reactions inpatients on VIT [80]. After 4 years of VIT, however, that correlation no lon-ger held true. Other immunologic changes occur that could also influencethe development of protection to insect stings. VIT seems to influence theT-cell phenotype away from the Th2-type, which produces interleukin-4and interleukin-5, and toward the Th-1 type, which produces interferon-g[81,82], or a regulatory type with expression of interleukin-10 and the pro-duction of IgG4 [83].

    Management of venom immunotherapy

    Safety of venom immunotherapy

    VIT generally is well tolerated. Most patients receive their injections in anallergist’s office until the maintenance dose is reached. Patients should re-main for 30 minutes after each injection in a setting equipped to handle a sys-temic reaction. About 3% to 12% of patients have treatment-inducedsystemic reactions that generally are mild and occur in the early phases ofVIT [15,84]. The reaction rate is no higher than that seen in conventional

  • 223INSECT STING ALLERGY

    pollen immunotherapy when effective immunizing doses are used [85]. Ifa systemic reaction occurs, the regimen is interrupted. One half of thedose that resulted in a systemic reaction is given the next week and, if toler-ated, the schedule is resumed. Pretreatment with antihistamines reduces VITreactions and may improve the efficacy of VIT [86,87]. A less serious, butmore frequent, problem with VIT is the large local reactions that occur in25% of children and 50% of adults, usually at doses about 20 to 30 mg. Al-though bothersome, they do not predict an increased risk of future systemicreactions to treatment and usually the best way to avoid them is to reachhigher doses by proceeding with the injections regimen. Further advice indealing with difficult cases can be found in the literature [88].

    All new forms of treatment provoke concern of possible long-term com-plications. Yunginger and coworkers [89] provided some information re-garding venom safety by studying beekeepers and their families who mayexperience as many as 50 or more stings per year. Although this populationshowed some minor urine or blood chemistry abnormalities, these did notshow a correlation with sting frequency. Also, beekeepers do not have anincreased risk of cancer. It should be noted, however, that parallel studiesfor vespid venoms are not available. No long-term toxicity or side effectshave been associated with VIT thus far. Graft and coworkers [14] notedthat 3 to 6 years of VIT in children was not associated with abnormalitiesin histories; physical examinations; or laboratory analyses (hematologicand chemical surveys, and urinalyses).

    Few reports of VIT use during pregnancy have been published. Schwartzand coworkers [90] discussed 22 pregnancies in 15 women that resulted in 19normal children, 1 first-trimester miscarriage, 1 miscarriage secondary toplacenta previa, and 1 child with multiple congenital abnormalities of un-known cause. This rate of less than optimal outcome for pregnancy wasnot higher than expected with pregnancy in normal populations. In oneclosely studied case, VIT during pregnancy did not result in allergic sensiti-zation to venom in the child [91].

    Interval between venom injections

    The maintenance dose of 100 mg is given every 4 weeks for a year; the in-terval is usually lengthened to 6 weeks during the second year and to 8 weeksduring the third year of treatment [16]. Investigators from Israel described160 individuals who had the maintenance interval lengthened to 3 months[92]. A subgroup of 47 reached the 3-month maintenance interval only 4.5months after the maintenance dose was reached. Ninety-three stings in80 patients on 3-month maintenance interval VIT resulted in four skin reac-tions (one occurred in one of the few patients on a 50-mg maintenance dose).After VIT was stopped in these patients, 65 stings in 46 patients resultedin four reactions (6.2% per sting, 8.7% per patient). Extending the intervalbetween injections reduces the cost of VIT [93,94].

  • 224 GRAFT

    Monitoring of venom immunotherapy

    Most patients begin therapy with IgG levels less than 1 mg/mL (usuallyundetectable), but occasionally they may be elevated because of the previoussting. IgG levels induced by the first 4 to 6 months of therapy are usuallybetween 5 mg/mL and 20 mg/mL, with higher levels observed in childrenand when multiple venoms are administered [80]. Among immunized pa-tients, those who continue to react to stings generally have exceptionallysmall increases in their venom-specific IgG antibodies. Patients who arenot adequately protected by the 100 mg per venom dose are often protectedwith higher doses [95]. Because there are so few treatment failures with VIT,it may not be cost-effective to perform venom IgG antibody assays on allimmunized patients [96].

    At follow-up visits, usually annually, the patient’s VIT schedule shouldbe reviewed, noting dose and frequency of injections; local or systemic reac-tions to injections; and any stings (and their outcome) that may have oc-curred since the last visit. VSTs may be repeated every several years. Overtime, VSTs tend to decline and become negative in a significant proportionof patients. In children, Graft and coworkers [97] found that 45% of thosewho had received 3 to 6 years of VIT developed negative VSTs to one ormore venoms, whereas in adults, Golden and coworkers [98] reported that20% had negative VSTs after 5 years and 50% to 60% after 7 to 10 years.

    Honeybee allergy versus vespid allergy

    Honeybee sensitivity is generally a more difficult problem than vespidvenom sensitivity. Researchers in The Netherlands stung 324 patients andfound that patients with history of honeybee sting reactions were twiceas likely to react to challenge stings (52% versus 25%) [60]. Once VIT iscommenced, Müller reported that honeybee-sensitive patients have more re-actions to VIT (41% versus 25%) than those on vespid VIT [54]. Of concern,honeybee VIT is less effective in preventing future sting-induced systemic re-actions (77% versus 91%) [54]. Finally, even after VIT is stopped, patientswho received honeybee VIT are more than twice as likely to react to chal-lenge stings (17% versus 4%–8%) delivered 1 to 2 years after VIT discontin-uation [99].

    Discontinuation of venom immunotherapy

    In 1998, the American Academy of Allergy Asthma and Immunologypublished a position statement on the discontinuation of hymenopteraVIT [17]. This reviewed data that had been published on outcomes of pa-tients who stopped VIT without a physician’s recommendation; those whowere able to stop VIT because they developed negative VSTs or significantlylower levels of venom-specific IgE; and those who had completed a specificduration of VIT, such as 3 or 5 years. Most have used challenge stings;

  • 225INSECT STING ALLERGY

    others have reported on the outcome of natural field stings. Importantly, thelack of certainty of identification of the insect clouds the interpretation ofstudies that used field stings.

    When VIT was first used, many thought that it would need to be contin-ued indefinitely. Early on, however, reports began to appear that chronicledthe relatively good outcomes of patients who chose to stop their venom in-jections. Reisman and coworkers [13] reported from Buffalo on 88 patients,ages 10 to 76 years, who stopped VIT after 1 to 78 months without a physi-cian’s recommendation. Of these, 61 field stings in 41 patients occurred 1 to72 months after VIT was terminated and there were 11 (18%) systemic re-actions. In Baltimore, Golden and coworkers [100] noted a 22% reactionrate in patients who stopped treatment after 2 to 44 months of venom injec-tions. These rates were much lower than the approximately 60% risk for un-treated patients with histories of sting-induced systemic reactions andpositive VST.

    Next, studies were designed in which VITwas discontinued if the venom al-lergy had significantly diminished as measured by the fall in venom-specificIgE to low levels. Studies in which the VST became negative reportedlow numbers of entrants [33,97]. Urbanek and coworkers [101] studiedthe discontinuation of VIT in 31 honeybee-sensitive children and adoles-cents in whom venom-specific IgE had fallen to low or unmeasurable lev-els. One year after stopping VIT, a challenge honeybee sting resulted ina systemic reaction in only 1 (3%) of 29 patients; at 2 years after stoppingVIT, 2 (14%) of 14 patients reacted. Randolph and Reisman [102] re-ported an 8% reaction rate to stings in patients who stopped VIT becauseof a two-log decline in venom-specific IgE levels. Studies using serum ven-om-specific IgE levels have been criticized because of potential for variancein assay methods and scoring systems between investigators. Reisman [103]retrospectively reviewed the outcome of 217 field re-stings in 113 patientsafter discontinuation of VIT and reported a relationship between the se-verity of the pre-VIT insect sting reaction and the likelihood and severityof sting reactions after a course of VIT was stopped. Systemic reactionsoccurred in 1 (4%) of 25 patients with initial mild reactions; 2 (5%) of41 patients with initial moderate reactions; and 7 (15%) of 47 patientswith initial severe reactions. In the latter group, five of the seven reactionswere again of a severe nature. Furthermore, in Minneapolis a retrospectivestudy found that 148 stings in 117 patients (most were intentional chal-lenge stings) who had discontinued VIT resulted in only two reactions,both of which occurred in patients with initial severe sting reactions [104].

    Most recently, studies have been designed in which VIT is administeredfor a specific duration of time. Haugaard and coworkers [105] of Denmarkreported the outcome of sting challenges in 25 adults (mean age, 42.9 years)who had moderate to severe systemic reactions; were primarily yellow jacketsensitive; and had been on VIT for 36 to 83 months (mean, 42.8 months).Twenty-eight sting challenges with the relevant insects 12 to 36 months

  • 226 GRAFT

    (mean 25.2 months) after VIT was stopped resulted in no systemic reactions.In Switzerland, Müller and coworkers [99] studied 86 children and adultswho had received honeybee venom for a mean period of 56.4 months (range,32–119 months). All patients had tolerated a honeybee sting in the field or ina hospital challenge setting while receiving VIT. About 13 months (range,10–24 months) after VIT was discontinued, patients returned for deliberatehoneybee sting challenges, and 15 patients (17%) experienced mild systemicreactions.

    Keating and coworkers [106] studied 51 patients in Minnesota after ces-sation of VIT for 2 to 10 years (mean, 5.2 years). Vespid VIT was adminis-tered to 46 patients, with 15 patients receiving honeybee venom injections.All patients tolerated stings by the relevant insects at the time VIT was dis-continued. One year after stopping VIT, two patients reacted to intentionalchallenge stings; these patients resumed VIT. Further sting challenges(N ¼ 31) resulted in no reactions. Two of 15 patients with initial severe re-actions had reactions to challenge stings compared with none of the 36 pa-tients with milder reactions. Also, the risk of reaction was higher in the 13patients who received VIT for less than 5 years (2 of 20) than in the patientswho received VIT for more than 5 years (0 of 31).

    At Johns Hopkins in Baltimore, Golden and coworkers [98,107,108] per-formed the most comprehensive trial of discontinuation of VIT. They re-ported the results of challenge stings in 74 adults allergic to insect venomwho had stopped treatment after 5 or more years of VIT. Eighty percentof these patients had a history of respiratory or vascular symptoms of ana-phylaxis after a pre-VIT sting. VST responses were negative in 28% whenVIT was discontinued (VIT duration: mean, 5.95 years; range, 5–9 years).One group of 29 patients was stung annually for 5 years; in year 4 theyhad two stings, 1 month apart. A second group of 25 patients had sting chal-lenges every 2 years; in year 4 off VIT they received two sting challenges,1 month apart. A third group of 20 patients had two stings 1 month apartafter 2 years off VIT. Systemic reactions followed 8 (3%) of 270 stings in 7(10%) of 74 patients [98]; only two reactions were clinically significant. Bythe end of the study, skin test responses were negative in 67% of the subjects.

    Subsequently, Golden and coworkers [107] reported on their extendedfollow-up for these and other patients. Of the original 74 patients in theirchallenge sting study, 11 sustained field stings after 3 to 7 years off VITand one developed a systemic reaction involving dyspnea. Of an additional51 patients, 4 of 15 stings results in systemic reactions. In total, 12 (13.5%)of 89 patients had 14 (4.5%) reactions to 309 stings. Patients who had a sys-temic reaction to a venom injection or insect sting during VIT had a 46%rate of systemic reaction to stings after VIT was discontinued as comparedwith only 8% rate in those who had no reactions during VIT. Patients withmore severe pre-VIT reactions did not have a higher frequency of reactionsto stings but did tend to have more severe reactions. A follow-up papernoted that insect stings had caused systemic reactions in 16 (14%) of 113

  • 227INSECT STING ALLERGY

    patients who were stung after discontinuing 5 or more years of VIT [108]. Itseems that patients with more severe reactions before VIT, patients who re-acted to stings or venom injections while receiving VIT, and patients withhoneybee-venom sensitivity tend to react to stings more frequently whenVIT is stopped. No two situations are identical. For some patients, a deci-sion to continue venom injections indefinitely, regardless of other factors,may be in order. Fortunately, most venom-treated patients can extend theinterval between maintenance injections to 6 to 8 or even 12 weeks after 2to 4 years of therapy.

    The American Academy of Allergy Asthma and Immunology PositionStatement [17] recommendations regarding discontinuation of VIT includethe following: (1) the decision should be made on the basis of a thoroughdiscussion of the issues by the physician and patient (individual patient var-iables, such as vocation or leisure activities, medications, and coexistent dis-eases, should be considered); (2) the conversion to a negative skin test is onecriterion for stopping VIT; (3) patients with mild or moderate sting reac-tions before VIT was initiated may discontinue VIT after 3 to 5 years;and (4) in patients with severe (hypotension, laryngeal edema, or broncho-spasm) sting reactions the physician may wish to continue venom injectionsfor more than 5 years and perhaps indefinitely (because most of even thesemost-at-risk patients tolerate discontinuation of VIT after 5 years of treat-ment, stopping treatment is an option).

    Summary

    Insect sting allergy has served as an excellent model for the allergic processover the past century. In particular, during the last 30 years, a new form ofdiagnostic testing and treatment with venom has been one of the great suc-cess stories in the entire field of allergy. VIT reduces the risk of recurrentlife-threatening reactions from about 60% to less than 2%. Progress and fur-ther questions continue with a search for a definitive diagnostic test that moreaccurately predicts which patients are at risk for future reactions, and defineswhich patients can stop VIT and which ones need to continue treatment.

    Acknowledgments

    I thank Robert N. Anderson, PhD, of the National Center for HealthStatistics for his efforts in providing the most current insect sting mortalitydata and Ms. Penny Marsala for librarian services.

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